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CHAP TER4 The back oftheneck
Useful investigations
Plainlms
The indications for cervical spine imaging following blunt force trauma
have been listed previously. This list combines the two main guidelines:the NE XUS Low- Risk Criteria and the Canadian C- SpineRules.
CT scanning
Three- view plain X- r ays are used in the majorit y of circumstances.
However, CT should be used in the following circumstances:
• Patient with a GCS score<13
• Intubated patients
• Inadequate plain lmseries
• Abnormality or suspected abnormality on plainlm
• Patient is being scanned for head injury or trauma series.
CT is also recommended in the following:
• Patients with dementia
• Patient with neurological signs likely to be of C- spineorigin
• Patient s with severe neck pain>7/ 10
• Patient with signicantly reduced range of movement
• Patients with known vertebral disease.
CT may also be used in the evaluation of non- traumatic symptoms and
signs, such as neck pain, stiness, lumps, and neurological symptoms if
MRI is not available.
MRI imaging
MRI should be used in patients with neurological signs likely to be cervical spine in origin and those patients with suspicion of ver tebral ar tery
injury. It is also useful as further imaging in those patients with severely
restricted neck movement or neck pain with normal CT scans. However,
in many centres MRI scans are not available out of hours and therefore
plain lms and CT scans are used as a stopgap. In those patients where
MRI is indicated, it should be carried out at the rst oppor tunity as its
sensitivity may fall af ter 48hour s.
Cervical spine plain film
interpretation intrauma
In trauma, the key image is the lateral cervical view and this should be
obtained rst as part of the initial assessment. However, before a cervical
spine can be cleared radiologically, adequate anteroposterior and odontoid peg views are also required. Peg views usually require the patient
to open their mouth. For that to be possible, the collar must be loose.
For this reason these views may be initially deferred. Do not interfere
with the immobilization until you have seen the lateral lm, unless the
situation demands that you need to. Assessment of plain lms can be
considered under the following headings.
Anterior vertebral line
s
Ve
CERVICAL SPINE PL AIN FILM INTERPR ETATION INTR AUMA
Adequacy
First determine whether the lm is adequate. Do not feel embar rassed in
rejecting a lm and asking for improved views. All radiographers involved
in trauma know how dicult it is to obt ain good lms and there a number
of dierent views they can use to help. An adequate later al lm shows all
seven of the cer vical ver tebrae, skull base, and the superior aspectofT1.
Interpreting thelateralview
This is a dicult radiograph to interpret, and deserves time. Consider
things in a logical order. Auseful approach is Alignment, Bones, Cavities,
and Disc (ABCD).
Alignment
The cer vical spine has a natural cur vature (cer vical lordosis). This may
be lost if there is muscle spasm. There are four curves to follow. Let
your eyes follow your index nger as you trace each one out. This allows
you to concentr ate on specic area s in turn, rather than be ooded with
information all at once. Each curve should be smooth and unbroken
(Figures 4.1 and4.2):
Posterior vertebral line
Spinolaminar line
Dens
Posterior spinous line
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Intervertebral
disc space
rtebral body
Figure4.1 Lateral cervicalspine.
Lateral mass
Facet joint
Lamina
Spinous proces
Pedicle
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CHAP TER4 The back oftheneck
Figure4.2 Note the angulat ion of C6 on C7 is gr eate r than 11 de gree s.
• Anterior line of the vertebralbodies
• Posterior line of the vertebralbodies
• Bases of the spinal processes (this may show a slight step of <2mm at
the levelofC2)
• Tips of spinal processes.
Bones
Examine inturn:
• Ver tebral body:below C2 these should have a fairly uniform
rectangular shape. Examine for any cortical discontinuity, change in
height, or wedging >3mm between anterior and posterior height.
• Atlas and axis (C1 and C2):in adults the posterior aspect of the
anterior part of C1 should be no more than 3mm from the anterior
aspect of the odontoid peg on the lateral lm. The posterior
aspect of the peg should make a continuous line with the posterior
partofC1.
• Posterior element s:the facet joints, lamina, and spinal processes
should all be examined for fractures.
Cavities
The pre- vertebr al sof t tissue shadow shouldbe:
• <7mm (or 30% of vertebr al body) at levels C1– 4and
• <22mm (or 1 ver tebral body width) atC5– 7.
An increase in this results from swelling and can be from an occult fr acture or underlying ligamentous injury.
CERVICAL SPINE PL AIN FILM INTERPR ETATION INTR AUMA
Discs
Intervertebral disc spaces should be of even height andshape.
Interpreting theanteroposteriorview
The spinal processes should all be in line with an equal gap between
them. No single space should be 50% greater than the one above or
below it. Each vertebral body should have a spinal process and two facet
joints; these can form a picture like an owl. Make sure each ‘owl’ has a
beak and two eyes. Some people have a normal variation of a bid spinal
process— this can sometimes be mistaken for a fracture.
Interpreting theopen mouth pegview
An adequate view includes the odontoid peg, lateral masses of C1, and
their relationship to the lateral masses of C2 (Figure 4. 3). The following
should betrue:
• There should be an equal distance between the peg and the lateral
masses of C1. This can sometimes be aected by rotation but can
also be a ssociated with subluxation.
• The lateral masses of C1 should align with the lateral masses of C2
with no overhang (this can indicate a burst fracture).
• The peg should have a smooth cortex with no steps or disruptions.
There are three dierent Peg fractures
• Avulsion of the tip (stable)
• At ba se of peg (unstable)
• Extends in vertebral body (unstable).
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Occipitocervical joint
Lateral mass of C1 atlas
C1/2 facet joint
Figure4.3 Ope n mout h ‘peg’v iew.
Odontoid peg
C2 axis
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CHAP TER4 The back oftheneck
Specific injuries totheneck
Serious injuries can be either bony or ligamentous in or igin. The latter is especially impor tant since the patient may have a normal looking
X- ray. So long as the spine is correctly immobilized, imaging can wait if nec-
essary until more pressing injuries are dealt with. Full C- spine immobilization
includes not just the neck, but immobilization of the entire spine. Movement
lower down the spine will result in a degree of movement in the neck.
Injuries of the cer vical spine may also be associated with spinal injuries
elsewhere, which also need to be protected.
Following signicant injuries, most patients arrive supinewith:
• Spine board:solid inexible plastic board with straps that hold the
patient rigid across the chest, pelvis, andlegs.
• Blocks:usually foam- lled rubber- coated blocks about the size of
a shoe box, on both sides of their head, preventing the neck from
rotating; they are radiolucent to allow radiographic examination of
thespine.
• Tape:often simple Elastoplast®- type tape, but more commonly two
purpose- made straps, one across the mandible, the other across the
forehead, holding the head down on to the spinalboard.
• Hard collar:sti plastic collar that prevents exion, extension, and
lateral exion of the neck. The patient cannot open theirmouth.
Go to your emergenc y department , and ask to see these items. Become
familiar with how they are applied and takeno.
eFractures ofthe atlas(C1)
• Posteriorarch
• Anteriorarch
• Jeerson fracture (blowout fracture through anterior and posterior
arches)
• Transverse process fracture
• Lateral mass fracture.
eFractures ofthe odontoid peg(C2)
• Tip of the odontoid process
• Through the base of the odontoid
• Through the odontoid and extends into the body of the vertebra
• Fracture associated with unilateral or bilateral facet dislocation of
C2onC3.
Hangman’s fracture
This is a fracture of the C2 posterior elements produced by extension
and distraction (Levine classication).
eFractures ofthe vertebralbody
• Wedge compression
• Burst
• Tear- drop (Figure4.4).
SPECIFIC IN JUR IES TO THENECK
Figure4.4 Tear- d rop f rac tureofC6.
eFacet joint injuries
• Occipito- cervical dislocation
• Atlanto - axial subluxation (odontoid distance is>3mm)
• Unilateral facet dislocation (25% displacement of the upper vertebr a
on the lower, or malalignment of the spinous processes on the
anterior- posteriorlm)
• Bilateral facet dislocation (50% displacement of the vertebr a)
(Figure4.5).
eSCIWORA (spinal cord injur y withoutradiological
abnormality)
Patients can occasionally sustain signicant spinal cord injuries without
any changes radiologically. This is more common in the paediatr ic population (due to increased elasticity of the ligaments), but can also occur
in adults with underlying bone disease of the neck. If suspected an MRI
should be carried out— this can reveal haematoma or oedema within
thecord.
cNeck sprain (‘whiplash’)
This is a very dicult diagnosis to prove (or disprove) or quantify, and
is a potential mineeld when it comes to litigation. It is a spr ain of the
surrounding neck muscles, notably trapezius and the deep extensors.
‘Whiplash’ is a controversial term. Anyone who has had a neck sprain
will appreciate how painful it is. Muscle bres are torn, resulting in
intense painful spasm. The neck is held still by this spasm and the muscles
feel hard. Sometimes the head is rotated to one side due to the pull of
the sternomastoid. Radiographs can be dicult to interpret as spasm
can distor t the normal position of the neck , twisting it or straightening
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CHAP TER4 The back oftheneck
Figure4.5 Bilateral fa cet dis locat ion of C5 on C6. Note 50% overla p.
its natural lordosis. Loss of the normal curvature of the cervical spine on
a lateral view suggests muscle spasm and therefore injury. This is a useful
radiographic sign. If a signicant neck injury cannot be ruled out, CT is
required. Management involves analgesia (NSAIDs) and physiotherapy.
Pain may get worse before it gets better but should improve 3– 4days
post in jur y.
eHanging
Some patients may at tempt (and fail) to commit suicide by hanging them selves. This can result in several injuries depending on the method/
equipmentused:
• Upper airway injury and asphy xiation
• Cerebral hypoxia from carotid occlusion
• Cerebr al oedema and ischaemia from jugular vein occlusion
• Carotid sinus reex resulting in bradycardia and cardiacarrest
• Vertebral arter yinjury
• Cervical fracture with spinal cord injury.
If a rope is used, the location of the knot is a major factor in deter mining
the mechanics of any injur y. The face may be engorged and cyanotic with
petechiae in the eyes. Forensic exper ts may be able to tell if hanging is
attempted suicide or attempted homicide by the ligature mark . If the
hyoid bone is broken, this may be a clue to manual choking. Take photographs and keep any ligature/ rope for the police.
SPINAL CORD INJURY/LESIONS
eSpinal cord injury/ lesions
Spinal cord injur y can vary widely, with symptoms that include pain,
paralysis, and incontinence. It can r ange from ‘incomplete’, with varying eects, to ‘complete’, with total loss of function below the level of
the lesion. Spinal cord injuries have many causes, but are usually associated with major trauma from MVCs, falls, spor ts injuries, and violence.
However, they can also be of a non - traumatic origin, secondary to malignancy, infection, intervertebral disc disease, and spinal cord vascular
disease.
Classication
The International Standards for Neurological Classication of Spinal
Cord Injur y (ISNCSCI) is a useful classication. Traumatic spinal cord
injury can be classied into ve categories:
• A:‘complete’ spinal cord injur y where no motor or sensor y function
is preserved in the sacral segmentsS4 – S5.
• B:‘incomplete’ spinal cord injury where sensory but not motor
function is preserved below the neurological level and includes the
sacral segments S4– S5. This is usually a transientphase.
• C:‘incomplete’ spinal cord injury where motor function is preserved
below the neurological level and more than half of the muscles below
the neurological level have a power grade of less than3.
• D:‘incomplete’ spinal cord injury where motor function is preserved
below the neurological level and at least half of the key muscles
below the neurological level have a muscle grade of 3 ormore.
• E:‘normal’ where motor and sensor y scores are normal.
(Reproduced from ‘International Standards for Neurological Classication of Spinal Cord Injury:Cases with classication challenges’, S.C.
Kirshblum, F.Biering- Sorensen, R. Bet z, et al., The Journal of Spinal Cord
Medicine, 37, 2, 2014, reprinted by permission of the publisher (Taylor &
Francis Ltd, http:// www.tandfonline.com).)
It is important to deter mining the exact ‘level’ of injury. This is
described according to the vertebr al level at which the injur y occurs.
While the prognosis of complete injuries is poor, the symptoms of
incomplete injuries can vary, making it dicult to predict outcome.
eCervical injuries
These usually result in tetraplegia. However, depending on the location
and severit y of injury some function may be retained:
• Injuries at C3 vertebrae and above often result in loss of breathing,
necessitating intubation and ventilation.
• Injuries at, or below, C4 variably aect the upperlimb.
Additional features include:
• Reduced ability to regulate heart rate, BP, sweating, and body
temperature.
• Autonomic responses to pain are impaired.
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CHAP TER4 The back oftheneck
Initial management
Initial management of spinal cord injuries involves protecting the cord
and minimizing secondary inammation which may cause further damage. Traction should not be used (do not pull on the neck). The neck
should be immobilized above and below the suspected level of injur y.
In the early stages of injury, patients may develop neurogenic shock, respi ratory failure, and pulmonar y oedema. Careful assessment for these should
be made. The mean ar terial BPs must be carefully maintained (of at least
85– 90mmHg) using IV uids, transfusion, and vasopressors under specialist advice. Later complications include pressure sores, pneumonia,
pulmonary emboli, and deep venous thrombosis. Appropriate preventive measures should therefore be commenced. The role of high- dose ste-
roids is controversial so seek advice before giving these. When trauma has
not been involved, a careful search for the under lying pathology (notably
tumours or disc protrusion) is made. Specic treatment varies depending
on the cause as well as its location and severity of signs. Traumatic spinal cord injuries require considerable physiotherapy and rehabilitation.
Experimental treatments include controlled hypothermia and stem cells
technolog y, although these are still in the early stages of research.
eSpinal cord syndromes
A number of spinal cord syndromes have been described. These occur
as a result of injur y to some of the ascending and descending tracts of
the spinal cord, while others remain intac t and functional. Knowledge of
spinal cord anatomy helps interpret these ndings.
Central cord syndrome(CCS)
CCS is a form of incomplete spinal cord injur y characterized by weakness
in the arms and hands while the legs are involved to a lesser extent. It is
usually caused by injury to the cervical or upper thoracic regions of the
spinal cord. It occurs as a result of ischaemia, haemorrhage, or necrosis
in the central por tions of the spinal cord. The more peripher al cor ticospinal bres for the legs are therefore spared.
Underlying causes include atherosclerosis, trauma, emboli, and diseases of the aorta. CCS often occurs in older patients with cervical
spondylosis following a hyperextension injury, so should be considered
in any elderly patient presenting with facial injuries who ha s fallen ‘at on
their face’. However, it also may occur in younger patients. CCS accounts
for approximately 9% of traumatic spinal cord injur ies and is generally
associated with a more favourable prognosis compared to the other
syndromes. In many cases neurological symptoms improve with conservative management (immobilization of the cervical spine with a neck
collar for approximately 6 weeks). Surgical intervention (stabilization
or decompression) may be required if there is instability of the cervical
spine or if symptoms progress.
Anterior cord syndrome/ anterior spinal artery syndrome/ Beck’s syndrome
This is often associated with exion- type injuries to the cervical spine,
causing damage to the anterior portion of the spinal cord. Other causes
include atherosclerosis, aortic aneurysms, dissections, direct trauma
to the aorta, and surgery to the mediastinum. These can damage or
obstruct the branches of the aorta that supply the anterior spinal ar tery,
SPINAL CORD INJURY/LESIONS
which itself supplies the anterior portion of the cord. Acute disc herniation, cervical spondylosis, kyphoscoliosis, and neoplasia can also result
in occlusion of the anterior spinal arter y. Rarer causes include vasculitis,
polycythaemia, sick le cell disease, decompression sickness, cocaine use,
and connective tissue disorders.
Below the level of injury, motor function (corticospinal tract), pain
sensation, and temperature sensation (spinothalamic tract) are lost.
However, touch, proprioception, and vibration sense remain intact (dorsal columns). Areexia, a accid anal sphincter, urinary retention, and
intestinal obstruction may also occur. Treatment depends on the primary
cause. Prognosis is generally poor. The mortality rate is approximately
20%, and 50% of individuals show very little or no change in symptoms.
Posterior cord syndrome/ tabes dorsalis
This can also occur, but is very rare. It is caused by an injury or lesion
aecting the posterior spinal arter y in the posterior portion of the spinal cord. This results in loss of proprioception below the level of injury.
Motor function, sense of pain, and sensitivity to light touch remain
intact. Tabes dorsalis is demyelination secondary to an untreated syphilis
infection.
Brown- Séquard syndrome
This usually occurs when the spinal cord is hemisectioned or injured on
one side, usually from a penetrating wound (e.g. gunshot or knife injury).
Rarer causes include tumour, multiple sclerosis, and tuberculosis (TB).
On the ipsilateral side of the injury there is loss of motor function, proprioception, vibration, and light touch. Contralaterally, there is a loss of
pain, temperature, and crude touch sensations. Treatment is directed
at thecause.
cSyringomyelia
This refers to the formation of a cyst or cavity (syrin x) within the spinal
cord. This expands over time, compressing the spinal cord (Figure4.6).
Symptoms include pain, paralysis, weakness, and stiness in the back,
shoulders, and extremities. Syringomyelia may also cause loss of the ability to feel ex tremes of hot or cold, especially in the hands. When syrinxes
aect the brainstem, the condition is called syringobulbia.
Arnold– Chiari malformation
This is the most common cause of syringomyelia. Acongenital abnormality of the brain causes the lower part of the cerebellum to protrude into
the cervical por tion of the spinal canal. Asyrinx may then develop in the
cervical region of the spinalcord.
Acquired syringomyelia
Syringomyelia may also occur as a complication of trauma, meningitis,
haemorrhage, a tumour, or arachnoiditis. Here, the syrinx develops in
the part of the cord previously damaged by one of these conditions. It
can then expand.
Investigations include MRI and myelography. Referral to a neurosur-
geon is required. Treatment includes drainage of the cyst and placement
of ashunt.
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